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Early diagnosis is key to treating diabetes-related vision loss

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Shelly Laninga did not assume the worst when she started to experience blurred vision in her left eye in the fall of 2011.

After all, it wasn't the first time she had trouble with her vision. In 2009, the 46-year-old mother of two had been diagnosed with cataracts in both eyes and underwent surgery to correct the problem. Her vision had been crystal clear ever since.

So when her left eye started acting up again, she thought it was probably a relatively minor issue, one that could be easily addressed. She was only partly correct.

As it turned out, Laninga's latest eye problem was a bit more complicated than she initially thought. Instead of a minor irritation, Laninga was diagnosed with diabetic retinopathy - a microvascular complication of diabetes that can lead to vision loss and blindness.

But Laninga was right about one thing. The staff at the Winnipeg Health Region's Buhler Eye Care Centre would be able to help her, just as they did when she developed cataracts in 2009.

Located at Misericordia Health Centre, the Buhler Eye Care Centre is the largest surgical and eye treatment clinic in Western Canada. With 26 surgical ophthalmologists on staff, the centre serves patients from Manitoba, Northwestern Ontario, the Territories and Nunavut, and performs about 10,000 eye surgeries each year.

Diabetic retinopathy is not an uncommon condition, according to Dr. Frank Stockl, an ophthalmologist at the Buhler Eye Care Centre. In fact, this condition is the leading cause of blindness in working-age people in North Amercia, and affects about 500,000 Canadians, the vast majority of whom have diabetes and are over the age of 45. And that number is expected to grow as Canada's population ages and the diabetes rates continue to rise. "Three to five per cent of the population worldwide is affected by diabetic retinopathy, and this number will increase as the population ages," says Stockl, who is also an assistant professor in the Department of Ophthalmology, Faculty of Medicine at the University of Manitoba. "By 2031, the diabetic population in Canada is expected to increase by 61 per cent."

The problem arises when high blood sugar levels caused by diabetes damage blood vessels in the eye. Over time, the blood vessels may weaken and leak fluid or become blocked, causing damage to the retina, which contains the cells that allow you to see clearly.

"They (blood vessels) are like a sealed garden hose," explains Stockl. "Diabetes can damage the inner-lining of these vessels and fluid can leak out. It's sort of like poking holes in a garden hose."

Fluid leaks can also occur if the blood vessels are "pulled." As Stockl explains, once the blood vessels become severely damaged, the eye starts building new ones. The problem is that the new blood vessels create scar tissue, which can then pull on the retina. "So you can think of them as being a really delicate garden hose being stretched or pulled. If you pull hard enough on those vessels, they'll start to leak." Eventually, all this leakage of fluid damages the cells within the retina, causing blurred vision and possible blindness.

Diabetic retinopathy is diagnosed just like many other retinal conditions affecting the eye. The pupils are dilated with drops and the eye is examined with lenses that magnify the view of the retina to see if there have been any changes, such as fluid in the retina or growth of abnormal vessels. Those living in remote northern areas of the province can be screened through the Manitoba Retinal Screening Vision Program. Nurses dilate the eye and take photos that are uploaded to a server and read by an ophthalmologist at the Buhler Eye Care Centre.

There are four stages of diabetic retinopathy, ranging from mild non-proliferative to proliferative disease, which is the most advanced stage of the condition and means the eye is producing abnormal blood vessels.

By the time Stockl had examined Laninga, her condition had progressed to proliferative diabetic retinopathy. Essentially, the blood vessels in her eye had become blocked or damaged to the extent that new blood vessels were growing. The new blood vessels were causing pulling on the retina, which in turn was causing her own blood vessels to leak fluid. The leakage had progressed to the point that it was affecting the function of the macula (which is the part of the retina where our central and most important vision occurs), causing Laninga to lose her vision.

In the earlier stages of diabetic retinopathy, a patient might undergo laser surgery to seal the blood vessels and prevent leakage. But Laninga would require more comprehensive treatment.

Stockl decided the best course of action was to surgically remove the abnormal blood vessels from the eye, a procedure known as a vitrectomy. He then used a laser to seal the leaking blood vessels to prevent further leakage and regrowth of the abnormal vessels.

In addition, Laninga was given a dose of Avastin, a drug that helps keep blood vessels from expanding and leaking, in her left eye. Stockl is hoping to avoid using Avastin for the right eye. "Laser treatment should stop the growth in the vessels in the right eye, but she might (need Avastin), it is possible."

Vitrectomies have been performed since the 1980s, but in the last 10 years, there have been many improvements to techniques and the instruments that are used. One of the major advances is that the incisions used to gain access to the back part of the eye have become much smaller.

While Stockl was able to surgically address Laninga's condition and preserve her eyesight, he says the most important tool in treating diabetic retinopathy is early diagnosis. "The real nightmare in diabetic retinopathy occurs in those people not screened," he says. "Screening is critical. People with diabetes should have their eyes checked at least once a year, but we know that 30 to 50 per cent of them do not receive proper diabetic screening examinations."

Early diagnosis means more effective treatment. While Laninga suffered blurred vision prior to being diagnosed, people with the condition do not always have symptoms. "The condition can advance a lot without the patient knowing it," says Stockl.

While people who have had diabetes for 10 years or more are at high risk of developing some form of diabetic retinopathy, many will be able to limit the severity of the condition by keeping their diabetes in check. That means controlling your blood pressure and blood sugar level. "Those with poor diabetic control are more at risk," says Stockl. "A lot of people with diabetes are unaware of how devastating the disease can be if it progresses to advanced stages. It can rob you of your vision and cause loss of independence. You can lose your driver's license, your employment. The results can be devastating."

One challenge in trying to reduce the damage from diabetic retinopathy is raising awareness about the connection between diabetes and vision loss. "Diabetes is the leading cause of blindness," says Stockl. "Yet many people don't even know they have diabetes."

As a result, one of the best ways to avoid diabetic retinopathy is to reduce your risk by maintaining good blood sugar control. Laninga was diagnosed with Type 1 diabetes at age six months. Type 1 diabetes is unavoidable and means your pancreas stops producing insulin.

In contrast, Type 2 diabetes is much more influenced by lifestyle, which means it can be prevented for many people. Generally speaking, Stockl says, people can reduce their risk of developing or at least slow the progression of the devastating complications of Type 2 diabetes by leading an active lifestyle, maintaining a healthy weight, eating a balanced diet, and watching their cholesterol and hypertension (blood pressure). "Smoking is also a potential risk factor that may make diabetic retinopathy worse, says Stockl.

Following her eye surgery, Laninga took a month off from her job at Academy Dental to recuperate. Today, life is pretty much back to normal. She continues to enjoy working, bowling, gardening, and cheering on her sons Mackenna, 9, and Quinn, 8, as they play hockey.

And, despite the seriousness of her condition, she remains undaunted.

"It's my personality," she says. "I don't get down about things. Worrying and fretting just drives you insane. I know I am in good hands with a good doctor. I just have to be trusting. "It's amazing what they can do now. Dr. Stockl is amazing. I can't believe how many people the clinic sees in a day. Some drive in from Brandon and Ontario to see the specialist," she says.

"There is always something in life. If you don't accept what has happened to you and learn to live healthy, life is way too short to say, ‘Why me?' I have a wonderful husband - Greg Lyon - and two beautiful children.

"You just have to go with it. You have always got to look for the good in life."

Liz Katynski is a Winnipeg writer.

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Diabetic retinopathy

What is diabetic retinopathy?

Diabetic retinopathy is an eye problem caused by diabetes. It affects the retina, which is lightsensitive tissue at the back of the eye. Retinopathy occurs when diabetes damages the tiny blood vessels in the retina. This damage can lead to problems with your vision, including blindness.

However, you may be able to prevent severe vision problems if:

  • You keep your diabetes and blood pressure under control.
  • You have regular eye exams.
  • You get treatment for retinopathy when your doctor thinks it is necessary.

How does it occur?

High blood sugar levels damage small blood vessels. The weakened blood vessels may break and leak fluid and blood. Also, new abnormal blood vessels may grow. These new blood vessels can bleed, cause cloudy vision, and destroy the retina. The longer you have had diabetes and the worse your blood sugar control is, the more likely you are to have retinopathy.

What are the symptoms?

Diabetic retinopathy begins before you have any symptoms. As the problem gets worse, you may have:

  • Blurred vision
  • Floaters, which are black spots or cobweb-like shapes
  • Temporary or permanent blindness.

How is it treated?

Early treatment before the retina has been badly damaged is the most successful in reducing vision loss from this disease. Your eye surgeon may use a laser to reduce leaking from blood vessels. The surgeon may also use a laser to destroy abnormal blood vessels. If you have had bleeding into the clear gel (vitreous) that fills the inside of the eye, the eye surgeon may remove the gel with surgery. The gel will be replaced with a clear fluid. This procedure is called a vitrectomy.

How long will the effects last?

As long as you have diabetes, there is a chance you will have retinopathy. However, careful control of your blood sugar levels, blood pressure, and cholesterol will help delay and possibly prevent vision loss. You may need to be treated more than once for retinopathy. Have your eyes checked regularly to make sure you get treatment when you need it.

How can I take care of myself?

Follow your doctor's recommendations and these guidelines:

  • Make sure you have eye exams regularly. Ask your doctor how often your eyes should be checked.
  • Immediately tell your doctor if you have any change in your vision.

What can be done to help prevent diabetic retinopathy?

To help prevent diabetic retinopathy, follow these guidelines:

  • Control your blood sugar.
  • Control your blood pressure.
  • Control your cholesterol levels.
  • Quit smoking if you are a smoker.
  • Follow your diet and health-care plan for your diabetes so you have fewer complications.

Source: Health Links - Info Santé Manitoba

*   *   *

Common eye problems

Diabetic retinopathy is one of the four leading causes of blindness in Canada. The others are cataracts, glaucoma, and age-related macular degeneration. Here is a brief summary of each of the eye conditions and how they are treated.

Macular degeneration

Macular degeneration is caused by a change in cells within and under the retina, within the macula. There are two kinds: dry - accounting for 10 per cent of cases of severe vision loss, and wet - accounting for 90 per cent of cases of severe vision loss. Dry macular degeneration is when the cells don't function properly. Wet macular degeneration is abnormal blood vessels growing under the retina causing scarring, bleeding, and fluid leaking in the retina. People with dry macular degeneration are often advised to take a special formulation of high-dose vitamins to lower the chance of developing wet macular degeneration by 25 per cent. Wet macular degeneration is treated with injections of an antibody (protein) that inhibits or stops the growth of the blood vessels. With treatment, there is a 90 per cent chance of stabilizing vision and a 30 per cent chance of improving vision.

Glaucoma

Glaucoma is a chronic condition caused by damage to the optic nerve - the nerve that connects the eyes to the brain. The fibres are damaged and degenerate. The only known treatable risk factor is increased pressure within the eye - something that would be detected with measurements taken at regular visits to an optometrist or ophthalmologist. Glaucoma is treated with drops and surgery, to help slow down the damage.

Cataracts

Cataracts are treatable. The lens within the eye becomes opaque over time as the protein in the lens fibres denatures. Cataracts can make night vision difficult by blurring vision, and creating halos around lights. They can also impair vision of things both near and far. Risk factors for the development of cataracts include: age, diabetes and trauma to the eye. Cataract surgery removes the old lens and implants an artificial one.

REMEMBER: Everyone should see their optometrist every year or two. Those with diabetes should be having their eyes examined once a year or more frequently, if recommended by their ophthalmologist.

*   *   *

About the Buhler Eye Care Centre

The Winnipeg Health Region's Buhler Eye Care Centre at Misericordia Health Centre is the largest comprehensive surgical and treatment centre of its kind in Western Canada.

In addition, to 14 in-patient beds, the centre features a remote screening program for northern communities and houses the Misericordia Lions Eye Bank.

The centre assesses and treats about 25,000 patients annually, and performs more than 10,000 eye surgeries, including 500 on an emergency basis.

It has 26 ophthalmologists, including four retinal surgeons, on staff, serving Manitoba, Northwestern Ontario, the Territories and Nunavut. Ophthalmology patients are cared for by an interprofessional team at the centre, which includes nurses, photographers, social workers, ophthalmology assistants, occupational therapists, home-care staff and outreach nurses who provide eyehealth promotion sessions and follow-up care.

Cataract operations account for 90 per cent of total surgeries, followed by retinal, glaucoma, cornea, globe, strabismus and orbit. The centre is a leader in cataract and retinal detachment procedures, and treatment for glaucoma and corneal diseases. Ophthalmologists also provide 24-hour on-call services.

The Retinal Screening Vision Program serves residents in Manitoba's northern Burntwood and Norman health regions. Residents attend clinics where specially trained nurses take digital photographs of their eyes. The photos are reviewed via computer by Buhler Eye Care Centre retinal specialists, who can detect diabetic retinopathy and other conditions and initiate referral for follow-up. Participants benefit by not initially having to travel to Winnipeg, while ongoing monitoring allows for the early detection and treatment of many diseases that can cause vision loss.

The Misericordia Lions Eye Bank also operates within the Buhler Eye Care Centre. More than 100 donations are made each year. The Eye Bank procures and evaluates eye tissues from donors that are used for corneal transplants, research and education.

 

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